HomeMy WebLinkAboutAUTH-07-2016-075000.TIF A CATAWBA COUNTY•
r+q � Public Health Department
pSubdivision
Q 184Environmental Health Division PIN# 371520812982
PO Bos 389. 100-A Southwest BI d,Ne+vtan,NC 28658 LOT# 3 & PT 4
NAME ON PERMIT: RODERICK HARGROVE, 4131 1ST STREET PL NW, HICKORY NC 28601
Site Address: 1550 46TH AV NE, HICKORY NC 28601
Property Size: Square Feet: 167,270.40 Acres:3.84
Directions: go north on McDonald Prkway, turn right onto 16th St PL NE, turn left onto 46th AV NE lot will be on your left.
/�/� Owner/Authorized Representative Acknowledgement of Permit Receipt
Yv/�'i certify that tam the owner or authorized agent(owner's authorization required) representing the owner of the
property described above.
&biAs the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service RBPR-12-2014-20500 by the following method(s):
2 Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
SAs the property owner or authorized representative I have reviewed and understand the specific conditions
r of the permit issued, and further understand that all applicable regulatory requirements specified under the North
Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or
Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the
construction of the wastewater system and/or water supply well permitted.
Permit Issue Date: 07/27/2016
Owner/Authorized Representative Signature ' Q •
----3Date 1f 7/Z°/� 0
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson sending permit)
Signature Date/Time
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpernnit 07/27/2016 08:24